2026 Triological Society Active Fellowship Application

2026 Triological Society Proposal for Candidacy for Active Fellowship

Deadline for Receipt of Materials Is October 1st
Name

First NameMiddle NameLast NameDegrees/Credentials
Gender
FOR THE COSM MEETINGS YOU MUST HAVE REGISTERED FOR THE TRIOLOGICAL SOCIETY PORTION OF THIS MEETING. Please check below the Triological Society meetings for which you have registered and attended. Within the previous five years, you must have attended a minimum of three meetings of national societies of the specialty, one of which must be a Triological Society meeting (attending a Triological Society meeting is applicable to domestic candidates only).
Other Meetings
I am Chair of an Academic Department.
I am a Residency Training Program Director.
Organization Name
Organization Address

Department

Work Street Address

Work CityWork State / Province

Work ZipWork Country
Home Address

Home Street Address

Street Address Line 2

Home CityHome State / Province

Home ZipHome Country
E-mail
Work Number

Area CodePhone Number
Cell or Home Phone

Area CodePhone Number
Year of certification by ABOto
Year & name of certification by other specialty board
Date of birth
Spouse/partner name
Send Society correspondence & publications to home or office?
Proposed by
Proposer email
Seconded by
Seconder email
Number of papers you have presented at Triological Society meetings within the last five years (No Text Numbers Only)
Number of papers you have presented at other national or international meetings within the past five years (No Text Numbers Only)
Number of scientific publications in peer reviewed journals as first or senior author (No Text Numbers Only)
Total number of scientific publications in peer reviewed journals (may include publications during residency) (No Text Numbers Only)
Number of national or international meetings other than Triological Society for which you registered and attended in the past five years (No Text Numbers Only)
College 1 [1. name 2. what years attended 3. degree]
College 2 [1. name 2. what years attended 3. degree]
PostGrad1 [advanced degree (excluding medical school)]
PostGrad 2 [advanced degree (excluding medical school)]
Medical school [1. name 2. what years attended 3. degree]
Internship 1 [1. where 2. what years 3. type]
Internship 2 [1. where 2. what years 3. type]
Residency 1 [1. where 2. what years 3. type]
Residency 2 [1. where 2. what years 3. type]
Fellowship 1 [1. where 2. what years 3. type]
Fellowship 2 [1. where 2. what years 3. type]
Current academic appointments 1 [1. type 2. name of medical school]
Current academic appointments 2 [1. type 2. name of medical school]
Current academic appointments 3 [1. type 2. name of medical school]
Current other/hospital appointments 1 [1. type 2. name]
Current other/hospital appointments 2 [1. type 2. name]
Current other/hospital appointments 3 [1. type 2. name]
Check national and international scientific and professional societies to which you belong
Other national or international societies (please give full name of society)
Have you received any grant funding since completion of residency? Please include information as outlined: Examples: (1) Triological Society Career Development Award, 8/1/2020 - 7/31/2022 (2) NIH K08, 7/1/2018 - 6/30/2023
PRIMARY FOCUS -- in which area do you spend the majority of your practice? (ONE CHOICE ONLY)
FOCUS 2 (if applicable) (ONE CHOICE ONLY)
FOCUS 3 (if applicable) (ONE CHOICE ONLY)
As an applicant for candidacy for Active Fellowship in the Triological Society, I agree to adhere to the current standards of ethical conduct as defined by the American Medical Association [Latest Medical Code of Ethics News | American Medical Association (ama-assn.org)] and endorsed by the Triological Society.
Initial and date
It is desirable for both the Proposer and Seconder to attend your Section business meeting and present you as their proposed candidate, however, at least one of them must attend your Section business meeting to speak on your behalf. In the event of an unforeseeable circumstance, and neither the Proposer nor Seconder can be present at the business meeting, those members present must unanimously agree to review your credentials without the benefit of the Proposer or Seconder. If the members do not unanimously agree to review your credentials without the Proposer or Seconder present, your application will be tabled. For International Candidates only: You will be a member of the section from which your proposers belong. If your 1st and 2nd proposers represent different sections, you may choose which section you wish to belong.

1. PROPOSER - upload your letter of recommendation here (in pdf form)

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2. SECONDER - upload your letter of recommendation here (in pdf form)

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3. APPLICANT - submit your recent photograph here

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4. APPLICANT - submit your current CV here (in pdf form)

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5. APPLICANT - submit your specialty board certificate here

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2026 Triological Society Proposal for Candidacy for Active Fellowship